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Irrational surgery

March 31, 2016

Cutting the lingual frenulum, or the uterosacral nerve “because it’s there”

Frenotomy

Frenotomy to treat breast feeding problems makes little sense. Some people can stick their tongues out further than others but, apart from a tiny minority with other problems, the ability is unrelated to health. Even if it was, cutting the frenulum, the midline fold of skin which we all have under the tongue, is unlikely to alter function.  The tongue is a big muscle; why would cutting a thin fold of skin in front of it matter? Orthopaedic surgeons don’t alter a muscle’s action by trimming round the edge, they remove it from its bony attachment and reattach it somewhere else. Even if the frenulum limited tongue movement, scars contract; cutting is just as likely to reduce mobility. You need z-plasties or similar to prevent contractures.

Empirical trials don’t support frenotomy either; most trials cut patients in the control groups within 48 hours so they could only measure the effect on very short term maternal pain (click here). The only trial which delayed cutting controls for two weeks was negative (click here). So why do up to 10% of babies get their “tongue ties” cut? Because it’s there.

tt4

Open the baby’s mouth and anyone can see it. Naive parents easily believe the story that it is limiting tongue movement. Cutting is easy, the baby can’t fight back, and complications are few. If the breast feeding problems resolve, the parents credit the operation. If they don’t, the surgeon can claim it was done too late, needs repeating, or doesn’t always work.

LUNA

Not so long ago laparoscopic uterosacral nerve ablation (LUNA) was the gynaecological equivalent of frenotomy for painful periods. Cutting the nerves to the uterus is not straightforward; an extensive plexus of nerve fibres lies deep in the retro-peritoneal space alongside the ureters and large arteries and veins. A proper nerve cutting operation, pre-sacral neurectomy, is difficult and risky; a last resort for women with disabling pain which can be treated in no other way. The results are modest at best.

But laparoscopy allows even ordinary surgeons to have a go. The uterosacral ligaments don’t contain many nerve fibres, but they need no fancy dissection to identify, and contain no important blood vessels.

us ligs

Any surgeon who could clip a Fallopian tube could do LUNA. Poorly designed studies suggested it might work, and it became a common and lucrative operation. Since most pelvic pain resolves with time many patients were convinced they’d been cured, and some surgeons made good money. A few women had complications, but if it works … .

Eventually a group of researchers the LUNA Trial Collaboration, did a proper randomised trial – including a sham incision on controls, vital to avoid a placebo effect (click here or LUNA trial full report. Full disclosure – I was a participating surgeon).

Result – absolutely no effect from LUNA.  Looking back it was obviously going to be so. There was no underlying logic. It was popular because it was there, and any old surgeon could do it. LUNA has pretty much died away from embarrassment.

Come on NHS. It’s time for one well-designed trial to send frenotomy the way of LUNA.

Jim Thornton

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3 Comments leave one →
  1. Sidler, Daniel, Prof ds2@sun.ac.za permalink
    April 1, 2016 6:50 am

    Dear colleague

    would you be willing to publish this in the South African Journal of Medicine?

    with best wishes

    Daniel Sidler

    [cid:dd179b33-39a1-4ad8-b066-8dd1fd628363]

    ________________________________

  2. April 1, 2016 7:13 am

    Delighted Daniel. I’ll email you. j

  3. Asem Ali permalink
    April 1, 2016 10:50 am

    Very interesting article. I completely agree that someone has to step up and look at this matter in a well structured way. Thanks Prof!

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